2016_1107 IRRIGATION DOMESTIC FIRELINE_�
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CIT'Y OF COPPELL PWS I.D. #0570040
(Customer) _
MAILING ADDRESS: "�-5�
CONTACT PERSON/PHONE: i�r��ly °t�O �1 3
LOCATION OF SERVICE:���J =„,�z_v���p_
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ODouble Check-Detector
❑PressureVacuumBreaker ❑Spill-ResistantPressure Vacuum Breaker
Manufacturer �l,,,�c� Model Number 2��R Size l�
Located At Serial Number �cS Z �S
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�d sid Held at 3�V psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight C� psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Hetd at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C Closed Tight❑ psid psid psid
Test gauge used:MakelModel��p yb-20b-�-�:J=►, SN:Qy t�Z�b�
Date Tested€or Accuracy: S�y/l L.
Remarks:
The above is certified to be true at the time of testing.
Firm Name,l��w..���,�1oc,c� F`,��. ���r�, Firm A ddress t���onc 2St��.Wo.�m..L�ac�t_T3(�'S�b$
Certified Tester(print);�1�..��Ih� Certified Tester(signahue)
Firtn Phone#2!'�.'�L4�I.7vt9'� Cert.Tester No.k�iPt90lZ.9'�� Date l���!(,�
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy